Which factor is most likely to delay healing in a patient with an open wound?
Presence of necrotic tissue.
Use of sterile dressings.
Regular wound irrigation with saline.
Excessive moisture in the wound bed.
The Correct Answer is A
A. Presence of necrotic tissue. Necrotic tissue (dead, devitalized tissue like eschar or slough) provides a medium for bacterial growth and acts as a physical barrier to the wound healing process, specifically inhibiting granulation and epithelialization. The body must first clear this debris, either naturally or surgically (debridement), before true healing can begin.
B. Use of sterile dressings. Using sterile dressings is a standard, essential practice in wound care to protect the wound from infection and maintain a moist, optimal healing environment. This promotes, rather than delays, healing.
C. Regular wound irrigation with saline. Regular irrigation with saline is the gold standard for cleansing open wounds. It removes debris, foreign material, and loose exudate without harming healthy cells, which is a key component of preparing the wound bed for healing.
D. Excessive moisture in the wound bed. While a moist wound bed is optimal for healing, excessive moisture (maceration) is detrimental because it causes the periwound skin to break down, which can enlarge the wound. However, the presence of necrotic tissue is a more direct and potent factor in stalling the core healing phases.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mechanical debridement: This involves using a wet-to-dry dressing or wound irrigation. It is non-selective (can damage healthy tissue) and not the most rapid method, especially for heavily infected wounds.
B. Autolytic debridement: This uses the body's own enzymes (via moisture-retentive dressings like hydrocolloids) to break down necrotic tissue. It is slow and generally contraindicated in heavily infected wounds because sealing the wound can create an anaerobic environment, potentially worsening the infection.
C. Surgical debridement: Surgical (sharp) debridement is the fastest and most effective method for removing large amounts of non-viable, infected, and exudative tissue. A heavily infected wound needs immediate reduction of the bioburden, which surgical debridement achieves quickly, moving the wound toward the healing phase.
D. Enzymatic debridement: This uses topical chemical enzymes (e.g., collagenase). It is slower than surgical debridement and often less effective at rapidly clearing the large amount of debris expected in a heavily exudative, infected wound.
Correct Answer is A
Explanation
A. To prevent shearing of the patient's skin: When a patient is pulled or dragged across a sheet, the deeper tissues (bone and muscle) are stationary while the skin moves, leading to shear injury—one of the primary mechanisms for Deep Tissue Pressure Injuries (DTPIs). Using a lift device raises the patient completely, eliminating this destructive shearing and friction force.
B. To make the repositioning process faster:While a lift device may be efficient, patient safety and skin protection are the clinical priorities, not speed.
C. To prevent the nurse from straining their back: This is an extremely important benefit for nurse safety and injury prevention, but the primary reason the intervention is implemented in the patient's plan of care is for the direct therapeutic benefit of protecting the patient's skin integrity.
D. To ensure the patient is positioned comfortably: This is a secondary benefit. While comfort is considered, the lift device's essential function is mechanical protection of the skin and underlying tissues.
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